Improve Your Lifestyle | Tuck Chiropractic Clinic

Personal & Contact Information

Which clinic do you plan to visit?

Legal Name*

First Name Last

Name you prefer to be called by:*

Gender*

Male
Female

Home Phone*

Mobile Phone

Cell Carrier

Email*

How would you prefer to be contacted?

Home Phone
Cell Phone
Work Phone
E-mail
Text Message

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

My Home Address is different from my Local Address

Local Address*

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth*

Month

Day

Year

Social Security Number

Are you employed?

Yes
No

Employer

Work Phone

Primary Language

Race

Ethnicity

Hispanic/Latino
Not Hispanic/Latino
Decline to Answer

Marital Status

Spouses Name (if applicable)

First Last

Spouse's Date of Birth

Month

Day

Year

Insurance Information

Would you like us to file with your health insurance?

Yes
No

What is your Insurance company?

What is your Insurance ID number?

If you have health insurance, who is listed as the primary policy holder?

I am listed as the primary policy holder.
Someone other than myself.

Name of Insurance Policy Holder

First Last

Insurance Holder's Date of Birth

Month

Day

Year

Who is responsible for this bill?

Emergency Contact Information

Emergency Contact

First Last

Emergency Contact's Phone

How did you hear about us?

Has anyone in your household been a patient here before?

Yes
No

Medical History

Past/Current Condition(s)

Allergies/Sinus - Food
Allergies/Sinus - Environmental
Allergies/Sinus - Medication
Cancer
Depression
Diabetes, Type 1
Diabetes, Type 2
Fibromyalgia
Headaches

Please list approximate date/age of diagnosis for any checked conditions:

Medical History - Surgical Procedures

Body Region

Abdominal
Back
Fertility/Birth Control
Gallbladder
Heart
Hernia

Please list approximate date/age of surgery for any checked areas:

Medication(s)

Please list any medications you are currently taking:

Start Date	Brand Name	Dosage	Condition

X-Ray Information and Consent

Are you pregnant?

Yes
No

I agree that to the best of my knowledge, I am not pregnant and Tuck Chiropractic has my consent to take x-rays.

Family Medical History

Mother

Father

Personal Health

Do you have a balanced diet?

Yes
No

Do you eat fast food frequently?

Yes
No

Do you take vitamins?

Yes
No

Do you excercise routinely?

Yes
No

Do you sleep well?

Yes
No

Do you smoke?

Yes
No

Do you drink alcohol?

Yes
No

Occupational History

What is your current occupation?

Describe your work:

Office/Computer
Light Labor
Moderate Labor
Heavy Labor
Stressful

What was your occupation prior to your current position?

What is your primary reason for visiting Tuck Chiropractic?

Location of present complaint:

Was there a particular event that caused the pain or problem?

Yes
No

If yes, please describe:

Are you a new or returning patient?

New Patient
Returning Patient

When did your present complaint begin?

What aggravates your condition/pain?

What lessens your condition/pain?

Are you feeling any of these?

Numbness
Pins and Needles
Burning
Aching
Stabbing
Dull Ache

Does the pain/sensation spread or radiate to other areas?

Yes
No

If yes, please describe:

On a scale of zero to ten, what is the severity of your pain RIGHT NOW?

0 = no pain, 10 = most severe pain

On a scale of zero to ten, what is the severity of your pain AT ITS BEST?

0 = no pain, 10 = most severe pain

On a scale of zero to ten, what is the severity of your pain AT ITS WORST?

0 = no pain, 10 = most severe pain

Is the condition/pain worst during certain times of day?

Yes
No

If yes, what time?

Since the condition/pain began, has it gotten:

Better
Worse
Stayed about the same

Review of Systems: Musculoskeletal and Nervous

In additon to the above conditon/pain, do you have any of the following symptoms?

Limited movement
Difficulty walking
Dizziness
Headache
Lack of coordination
Popping noises
Stiffness
Visual disturbances
Weakness

Name of Primary Care Physician

Have you been treated for any healthcare conditions by a physician in the last year?

Yes
No

If yes, please describe:

Is there another issue or pain also bothering you?

Yes
No

Location of present complaint:

Was there a particular event that caused the pain or problem?

Yes
No

If yes, please describe:

When did your present complaint begin?

What aggravates your condition/pain?

What lessens your condition/pain?

Are you feeling any of these?

Numbness
Pins and Needles
Burning
Aching
Stabbing
Dull Ache

Does the pain/sensation spread or radiate to other areas?

Yes
No

If yes, please describe:

On a scale of zero to ten, what is the severity of your pain RIGHT NOW?

0 = no pain, 10 = most severe pain

On a scale of zero to ten, what is the severity of your pain AT ITS BEST?

0 = no pain, 10 = most severe pain

On a scale of zero to ten, what is the severity of your pain AT ITS WORST?

0 = no pain, 10 = most severe pain

Is the condition/pain worst during certain times of day?

Yes
No

If yes, what time?

Since the condition/pain began, has it gotten:

Better
Worse
Stayed about the same

Do you have any other pain?

Is there any other pain you need to tell us about?

Yes
No

Location of present complaint:

Was there a particular event that caused the pain or problem?

Yes
No

If yes, please describe:

When did your present complaint begin?

What aggravates your condition/pain?

What lessens your condition/pain?

With this condition, are you feeling any of these?

Numbness
Pins and Needles
Burning
Aching
Stabbing
Dull Ache

Does the pain/sensation spread or radiate to other areas?

Yes
No

If yes, please describe:

On a scale of zero to ten, what is the severity of your pain RIGHT NOW?

0 = no pain, 10 = most severe pain

On a scale of zero to ten, what is the severity of your pain AT ITS BEST?

0 = no pain, 10 = most severe pain

On a scale of zero to ten, what is the severity of your pain AT ITS WORST?

0 = no pain, 10 = most severe pain

Is the condition/pain worst during certain times of day?

Yes
No

If yes, what time?

Since the condition/pain began, has it gotten:

Better
Worse
Stayed about the same

Patient Security and Disclosures

Acknowledgements*

I hereby instruct and direct my insurance company to pay by check made out and mailed to Tuck Chiropractic Clinic.
I authorize the release of information by any media pertinent to my case to any insurance company, adjuster, or attorney involved in this case, and verification of employment.
I also authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
I understand that I am financially responsible to Tuck Chiropractic Clinic for all charges incurred and not covered by the insurance, workers compensation and any collection, thirty-three and one third per cent (33 1/3%) attorney fees, interest and/or cost accrued in trying to collect this account.
I understand any balances over 90 days are subject to accrued interest of 1.5 percent per month.

I acknowledge that this information is true and correct.

HIPAA Compliance Acknowledgement of Receipt*

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notices of our privacy practice. We protect your health information and what rights you have regarding it, if we need to disclose your health information outside of our office for these reasons we will ask for your written permission. If you would like a copy of this policy please feel free to email or call our office and we would be happy to provide it to you.

I acknowledge that I have reviewed this policy and that I was offered a copy of the “Notice of Privacy Practices”.

Disclaimer*

Please note, submitting this form does not substitute for an office consultation. By submitting this form, no Doctor-Patient relationship is formed with Tuck Chiropractic Clinic. We will require you to come in for an in-office consultation. This will ensure that any care we provide is customized for each patient. It is important to remember that any information received through this website and email cannot be guaranteed to be confidential because of the possibility that a third party could intercept the message. Of course, once our office receives the information, it will be maintained in a confidential manner.

I have read and understand the disclaimers of this web site.

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Personal & Contact Information

Insurance Information

Emergency Contact Information

Medical History

Medical History - Surgical Procedures

Medication(s)

X-Ray Information and Consent

Family Medical History

Personal Health

Occupational History

What is your primary reason for visiting Tuck Chiropractic?

Review of Systems: Musculoskeletal and Nervous

Do you have any other pain?

Patient Security and Disclosures